KAE Cubs Pediatrics Medical Release

KAE Cubs Pediatrics Medical Release

Authorize KAE Cubs Pediatrics to release or obtain your child's medical records. Please complete all required fields.
Name of Parent/Guardian*
Complete Medical HistoryImmunization RecordsGrowth Charts and Developmental ScreeningsLaboratory and Imaging ResultsVisit Notes (e.g., well-child, sick visits)Medication HistoryOther
If Other, please specify
Name of Facility or Physician*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Purpose of Disclosure*
Patient Name*
Date of Birth*

MonthDayYear
Date
Name of Parent/Guardian (Printed)*
I understand that this authorization is voluntary and that I may revoke it at any time by submitting a written request. I also understand that once the information is released, it may no longer be protected under HIPAA. Unless otherwise specified, this authorization will expire one year from the date of signature below.

By signing below, I authorize the release or receipt of the medical information selected above.
Signature of Parent/Guardian*
Date (Signature)*

MonthDayYear
Date
Should be Empty: